电子健康记录与临床检查

The Electronic Health Record and the Clinical Examination.

作者信息

Hedian Helene F, Greene Jeremy A, Niessen Timothy M

机构信息

Division of General Internal Medicine, Johns Hopkins University School of Medicine, 10753 Falls Road, Suite 325, Lutherville, MD 21093, USA.

Department of Medicine, Johns Hopkins University School of Medicine, 1900 East Monument Street, Welch 324, Baltimore, MD 21205, USA; Department of the History of Medicine, Johns Hopkins University School of Medicine, 1900 East Monument Street, Welch 324, Baltimore, MD 21205, USA.

出版信息

Med Clin North Am. 2018 May;102(3):475-483. doi: 10.1016/j.mcna.2017.12.009.

DOI:10.1016/j.mcna.2017.12.009

PMID:29650069

Abstract

This review examines how the adoption of the electronic health record (EHR) has changed the most fundamental unit of medicine: the clinical examination. The impact of the EHR on the clinical history, physical examination, documentation, and the doctor-patient relationship is described. The EHR now has a dominant role in clinical care and will be a central factor in clinical work of the future. Conversation needs to be shifted toward defining best practices with current EHRs inside and outside of the examination room.

摘要

本综述探讨了电子健康记录（EHR）的采用如何改变了医学最基本的单元：临床检查。描述了电子健康记录对临床病史、体格检查、文档记录以及医患关系的影响。电子健康记录如今在临床护理中占据主导地位，并将成为未来临床工作的核心因素。需要将讨论转向确定在检查室内外使用当前电子健康记录的最佳实践。